Tips for Completion of Form 5- Consumer Registration Form

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					   Tips for Completion of Form 5- Consumer Registration Form

  I.     SAMS Details- Personal
         f. SSN- This form requests the last four digits of your Social Security
         number only; if you wish, you may choose to enter four zeroes

         g. Default Agency- Enter NCAAA (North Central Area Agency on
         Aging)

 IV. Assessment Form- Demographics (continued)
       d. Income- You may choose to check “Unknown”

 Please be sure to sign the Form 5- Consumer Registration Form, where indicated.

 Supplement to Form 5- Consumer Registration form:

 Medical Conditions: If none, please check “None”

 Allergies: If none, please check “None”

This information is collected for reporting to our current and future funding
sources and is useful for the Senior Center to have, especially during an
emergency.

				
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